New ACEP Guideline – Topical Anesthetics for Corneal Abrasion

March 6, 2024

Written by Megan Hilbert

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The ACEP consensus seems to indicate that it may be safe for patients with a simple corneal abrasion to go home with 24 hour usage of topical anesthetics for pain relief, but the ophthalmologists are not on board.

*Please note, any hedging language is intentional.

Eye can see clearly now the pain is gone
This was originally a joint venture between the American Academy of Ophthalmology (AAO) and the American College of Emergency Physicians (ACEP) to issue a joint consensus statement regarding use of topical anesthetics in simple corneal abrasion**. The workgroup (composed of members from both societies) used the Delphi method to review existing literature regarding topical anesthetic toxicity. Their literature summary and patient care recommendations were compiled and then submitted to the AAO and ACEP for approval; unfortunately, the AAO failed to support the recommendations and the Ophthalmology-based physicians requested to be dropped from the publication. ACEP did, however, go forward with publication.

There were no Level A recommendations made off the literature and there were many recognized limitations (ie: use of case reports/case series, lack of appropriate power, limited sample sizes, differing anesthetics used). Having said that, in simple corneal abrasions, it seems safe to provide topical anesthetic to be applied every 30 minutes for up to 24 hours with a max volume of 2mL upon discharge from the ED. There seems to be a demonstrated reduction in pain and relatively similar safety across different medications (tetracaine, proparacaine, and oxybuprocaine). Ultimately, the “typical” feared complications were demonstrated in individuals who used these products for a prolonged period of time (defined differently, but typically greater than 4 days). These recommendations do not encompass children and adolescents.

**Simple corneal abrasion is defined as those lacking corneal laceration/penetration, damage to other parts of the eye, duration of > 2 days, chemical or thermal cause, isolated UV photokeratitis, gross contamination, infection, retained foreign body, history of herpetic eye disease, underlying corneal pathology, history of corneal surgery or transplant, or other ocular surgery within the last month.

How will this change my practice?
I do not actively send my patients home with topical anesthetics for their simple corneal abrasion at this time. I think these recommendations will, however, embolden me to discuss this as an option with my ophthalmology colleagues. Of course, only as long as I have a reliable patient.

Source
Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines from the American College of Emergency Physicians. Ann Emerg Med. 2024 Feb 6:S0196-0644(24)00004-0. doi: 10.1016/j.annemergmed.2024.01.004. Epub ahead of print.